National Health Strategic Plan 2017 – 2021

1.1. Enforce, support and strengthen the health mandate including the core roles and functions of Te Marae Ora.

1.2. Provide support to strengthen general administrative and management responsibilities of the hospital and Community Health Service.

1.3. Provide support to strengthen general administration and management responsibilities for support services areas particularly kitchen, laundry, and maintenance to ensure ease and efficiency of operations.

1.4. Strengthening capabilities for health strategy development, policy reviews and formulation.

1.5. Formulate and review legislations to address and to be abreast with health service needs, demands and responsibilities.

1.6. Strengthen and support compliance and enforcement of health laws and regulations. DA 2. Health Finance

2.1. Strengthen financial control and monitoring of all health funding sources according to set standards.

2.2. Advocate for improved funding and budget allocation to TMO.

2.3. Support and facilitate annual budget planning and auditing processes.

2.4. Obtain and maintain an unqualified audit opinion on the Ministry annual financial reports.

2.5. Support and facilitate a feasibility study on financing options for health services. DA 3. Human Resource Development

3.1. Support and facilitate staff development as outlined in the Cook Islands Health Workforce Plan 2016- 2025.

3.2. Facilitate specialist training of staff especially in Paediatrics and Medicine.

3.3. Support training in echocardiogram diagnostic capability and ultrasound training for Medicine and Radiology service staff.

3.4. Support in-service training for Pa Enua nurses in both Community Health Services, patient care services, dental health, leadership and management. DA 4. Health Information

4.1. Strengthen resources which includes legislative, regulatory and planning frameworks required for an efficient health information system.

4.2. Strengthen and support enhanced institutional capacity and workforce development for sustainable infrastructure.

4.3. Improve data sources through capacity building activities and supervision mechanisms.

4.4. Enhance data management through written procedures and utilisation of a metadata dictionary.

4.5. Improve quality of health information products through accessible and improved dissemination of information on various electronic platforms, formats and through group forums.

4.6. Strengthen the application of information and communication technologies (ICT) which includes the introduction and use of “zoom” in all Pa Enua Health centers. DA 5. Health Research and Policy

5.1. Strengthen health research capability of the Ministry through appropriate institutional capacity building (human resource and financial).

5.2. Formulation a research plan that identifies and prioritize health research for the Ministry of Health and partners. DA 6. Health Infrastructure Page | 39

6.1. Ongoing assessment of health infrastructure and facilities including related support systems such as waste management and disposals.

6.2. Maintenance and renovation of existing hospitals and health centres including health residences.

6.3. New construction and extension to existing health facilities and related support systems to cater for expanding health services. KRA 1 Targets Certain targets have been selected and included in the monitoring and evaluation framework. DA 1. Leadership and Governance

1.1. Public Health Act 2004 revised by 2021

1.2. Formalised compliance and enforcement regime established

1.3. Review and formulate standards for sewage reticulation systems

1.4. Review of Nursing Clinical Guideline by 2018

1.5. Review Doctors Clinical Guidelines DA 2. Health Finance

2.1. Health appropriation improved to 5% of GDP;

2.2. Unqualified Financial Audit Reports obtained;

2.3. Maintained Performance Indicator as per the PEFA Framework

2.4. Feasibility study on health finance options DA 3. Human Resources for Health & Human Resource Development

3.1. Nurse Practitioners training Program established (2017/18).

3.2. Nursing bachelor degree completion training Program established with a recognised academic institution.

3.3. Training for new Pharmacy Technicians completed (2017/18)

3.4. POLHN training for 20 staff in the various cadre

3.5. Training for new Dental Therapists completed (2017-2018/19)

3.6. Training of new Public Health Inspectors completed (2017-18)

3.7. Post Graduate Public Health Nursing Training commenced DA 4. Health Information

4.1. Integrated ‘data warehouse’ created and functional at the national level.

4.2. Training on death certification for all medical officers and nurse practitioners and ICD code training.

4.3. Scoping Medtech evolution DA 5. Health Research and Policy

5.1. Health Research priorities for the Cook Islands developed.

5.2. Health Research Policy 2015 reviewed.

5.3. Conduct / facilitate anaemia prevalence survey in ante-natal women by 2018. Page | 40 Key Result Area 2: Community Health Services Community Health Services Department Aligned Directorate A. Policy Goal: To strengthen and improve community health care services under the principles of Primary Health Care and Healthy Islands context. B. Delivery Areas (DA): Delivery Area 1: Health Protection Delivery Area 2: Health Promotion Delivery Area 3: Family Health Services (Public Health Nursing) Delivery Area 4: Oral Health (Dental) Delivery Area 5: Mental Health C. Policies and Planning Strategies Linked to KRA The following specific plans are in existence and have been considered in the planning process of the KRA. C1. Program Specific Strategies and Plans C1.1 CI Integrated National Strategic Plan for Sexual and Reproductive Health 2014-2018 C1.2 National Strategy for NCD 2015-2019 C1.3 Tobacco Action Plan 2012-2016 C1.4 National Immunisation Policy C1.5 National Deworming Policy 2015 C1.6 Mental Health Policy 2015 C1.7 Mental Health and Wellbeing Strategy 2016-2021 C1.8 Suicide Prevention Strategy 2016-2021 C1.9 Oral Health Strategic Plan 2014-2018 C1.10 Sanitation (Wastewater Management) Policy 2016 C2. Sector-wide Policies and Planning Strategies Linked to KRA C2.1 Road Safety Strategy 2020 – 2025 C2.2 Sanitation (Wastewater Management) Policy 2016 C2.3 National Water Policy 2016 C3. Regional / Global Strategies C3.1 Healthy Island Strategy and Vision C3.2 Regional Strategy for NCD C3.3 International Health Regulation C3.4 Convention on the Rights of Persons with Disabilities C3.5 Community Based Rehabilitation guidelines C3.6 Convention on the Rights of a Child Page | 41 C3.7 Convention to eliminate all forms of discrimination against women (CEDAW) C3.8 WHO Community Rehabilitation Guidelines C3.9 Suva Declaration on improving oral health in the Pacific Islands Region C3.10 WHO Framework Convention on Tobacco Control KRA 2 Objectives The strategic objectives are operationalised yearly through the TMO Business Plan. The Business Plan will itemise the activities linked to the strategic objective. DA 1. Health Protection Strategic Objective Environmental Health

1.1. Implement Regulations in relation to the enforcement of health legislation.

1.2. Enforce Food Safety and Tobacco Control Regulations.

1.3. Improve and strengthen vector control.

1.4. Enforce sewage and sanitation regulation 2014.

1.5. Strengthen food safety and food standards.

1.6. Maintain and strengthen pollution control measures especially sewerage and medical waste management.

1.7. Maintain and strengthen water standards through monitoring, analysis and treatment of water storage.

1.8. Maintain and strengthen quarantine and border control support services at ports of entry.

1.9. Maintain and strengthen the International Health Regulations framework, ESR, Public Health Surveillance Network, Climate Change impacts, and disaster risk management. DA 2. Health Promotion Strategic Objectives NCD

2.1. Support and facilitate the implementation of activities outlined in the NCD Strategic Plan 2015-2019.

2.2. Support and strengthen prevention and management services for diabetes, hypertension and cardio vascular diseases.

2.3. Support and strengthen ongoing prevention activities against NCD risk factors.

2.4. Strengthen and support health communication strategies covering key risk factors.

2.5. Support research activities in NCDs and their risk factors. Nutrition

2.6. Support prevention of childhood obesity through nutrition Programs targeting school based approaches.

2.7. Support the Baby Friendly Hospital initiative.

2.8. Advocate for household food security and good nutrition through home/school gardening and healthy food preparations.

2.9. Develop a profile of nutrient intake for Cook Islanders using import data and Household expenditure survey data. STI/HIV

2.10. Implement activities and strategies outlined in the Sexual and Reproductive Health Strategy 2014- 2018. Page | 42

2.11. Support national and regional efforts to prevent the spread and minimise the impact of HIV/STIs on individuals, families and communities.

2.12. Strengthen the early detection of HIV and other STIs to reduce further infections and facilitate timely management and treatment. Tuberculosis

2.13. Support local TB control Program under the Global Fund strategies.

2.14. Strengthen and support awareness TB activities and management of TB in the community. Tobacco Control

2.15. Implement and strengthen Tobacco Control measures as outlined in the current Tobacco Control Action Plan and NCD Strategy. DA 3. Family Health Services (Public Health Nursing) Strategic Objectives Maternal and Child Health

3.1. Support and strengthen safe motherhood initiatives and Programs.

3.2. Strengthen Family Planning awareness.

3.3. Support and strengthen cancer screening and prevention Programs especially PAP smear and breast examination / screening. Immunisation

3.4. Support the maintenance of a strong EPI Program including good management of the cold chain to ensure high vaccine antigen coverage.

3.5. Support EPI disease surveillance and research. Child Health

3.6. Promote exclusive breastfeeding up to 6months.

3.7. Maintain and strengthen Maternal Child Health Clinic for follow up and care of children.

3.8. Maintain and strengthen School health programs and services.

3.9. Early Identification of developmental problems in children under 5 and referred. Rheumatic Heart Disease

3.10. Support screening Program for RHD.

3.11. Support referral and follow up treatment of RHD cases.

3.12. Ensure monthly injections for identified children are given. Family Health

3.13. Strengthen home visits to provide support for ongoing care of patients discharged from Hospital to prevent readmission within 28 days for the same diagnosis.

3.14. Strengthen palliative care services. DA 4. Oral Health Strategic Objectives

4.1. Strengthen current oral health services especially in schools and Pa Enua. Page | 43

4.2. Strengthening specialised oral health services to meet needs in the country.

4.3. Increase capacity and capabilities to meet needs in Rarotonga and Pa Enua.

4.4. Facilitate equipment and infrastructure procurement and development.

4.5. Implement activities identified in the Oral health Strategy 2014-2018. DA 5. Mental Health Strategic Objectives

5.1. Strengthen advocacy and awareness on alcohol and substance abuse.

5.2. Implementation of Mental Health and Well Being Strategy (2016-2021) and Suicide prevention strategy (2016-2021).

5.3. Support and strengthen community and institutional care and treatment.

5.4. Provide post-traumatic stress syndrome support/referral. KRA 2 Targets Certain priority targets have been selected and included in the monitoring and evaluation framework. DA 1. Health Protection Environmental Health 1.1. 100% of non-compliance issues are addressed within 48 hours of receipt.

1.2. Annual training in compliance and enforcement.

1.3. Less than 10 complaints received for non-compliance to Food Act and Regulation per annum.

1.4. Less than 10 complaints received for water borne related illnesses per annum.

1.5. Annual training on IHR and border security.

1.6. Zero vector borne outbreak. 1.7. 40% of all private dwellings inspected and assessed according to the Sewage Regulation 2014. 1.8. 50% commercial properties on Rarotonga and Aitutaki comply with the Sewage Regulation 2014.

1.9. Community Health Services Geographic Information System established.

1.10. At least 10 staff undertake and complete Pacific Data for Decision Making (DDM) Training program. DA 2. Health Promotion NCD

2.1. Reduce premature mortality due to NCD by 20% (4% per year) by 2020.

2.2. Complete implementation of Ngaki’anga Kapiti (NCD) strategy.

2.3. Review and development of new Ngaki’anga Kapiti (NCD) Strategy. Nutrition

2.4. Increase by 30% consumption of 5 or more serves of fruit and vegetables (survey based).

2.5. Reduce or maintain Primary school student obesity rate at 25%. Communicable Diseases

2.6. Achieve 100% Direct Observation Treatment (DOTS) coverage for Tuberculosis.

2.7. Maintain zero HIV. Tobacco Control

2.8. Enactment of Amendments to the Tobacco Control Act 2007.

2.9. Tobacco Free Ministry of Health by 2021. Page | 44

2.10. Reduce smoking by 20% of current level of smokers.

2.11. Percentage of Government premises compliant with current Tobacco Control Act 2007.

2.12. Declare one island/village as Tobacco free. DA 3. Family Health Services (Public Health Nurses) MCH/FP

3.1. Increase contraceptive prevalence rate to 35%.

3.2. All immunisation coverage is greater than or equal to 98%.

3.3. Establish baseline and targets for exclusive breast feeding rate on discharge from maternity ward at 3months and 6months.

3.4. Complete school physical health examinations every 2 years and report to school Principals within three months. Rheumatic Heart Disease

3.5. Complete screening of all children (5 to15years).

3.6. Completed repeat screening of high risk children subject to the initial screening.

3.7. Number of children receiving prophylaxis treatment.

3.8. Rheumatic heart disease screening in schools undertaken once every five years. Family Health

3.9. Reduce re-admission to the Hospital within 28days from discharge for the same diagnosis.

3.10. Establish a database for dependent elderly (60+) and those with disability on Rarotonga and Pa Enua. DA 4. Oral Health (Dental)

4.1. Implementation of the Oral Health Strategy 2014-2018.

4.2. Review and development of new Oral Health Strategy 2019-2022.

4.3. Reduction by 30% from the mean dmft 6.6 in 5 years old.

4.4. Reduction by 30% in tooth decay prevalence in Primary Schools (80%).

4.5. Reduction by 30% in the mean DMFT (7.3, 12.9 and 21.9) of the adult population of WHO indexed age groups. DA 5. Mental Health

5.1. Implementation of Mental Health and well-being strategy 2016-2021.

5.2. Implementation of Suicide Prevention Strategy 2016-2021.

5.3. Review and develop new Mental Health and wellbeing and Suicide prevention strategies.

5.4. Updated mental health register with diagnosis clearly tabulated.

5.5. Number of post-traumatic stress syndrome cases supported. Page | 45 Key Result Area 3: Hospital Health Services Department Aligned Hospital Health Services A. Policy Goal: To provide quality clinical care and services to meet the needs and expectations of patients and that are in line with the policies and resources of the Ministry of Health. B. Delivery Areas (DA): Delivery Area 1: Clinical Patient Care Services Delivery Area 2: Referral Services (Domestic and International referrals) Delivery Area 3: Specialist Care C. Policies and Planning Strategies Linked to KRA The following specific plans are in existence and have been considered in the planning process of the KRA C1. Program Specific Plans C1.1 National Strategy for NCD 2015-2019 C1.2 TMO Patient Referral Policy 2015 C1.3 National Health Information Strategy 2015-2019 C1.4 TMO Research Policy & Procedures C1.5 ICT Policy & Procedures 2011 C1.6 National Service Fee Schedule 2015 C1.7 Cook Islands Mental Health and Wellbeing Policy 2015 C1.8 Antibiotic Guidelines C1.9 National Action Plan on Antimicrobial Resistance C1.10 Infection Control Policy C2. Sector-wide Policies and Planning Strategies Linked to KRA C2.2 Gender Equality and Women’s Empowerment Plan of Action 2011-2016 C2.3 Road Safety Strategy 2016-2019 C3. Regional / Global Strategies C3.1 Healthy Islands Strategy and Vision C3.2 Regional Strategy for NCD C3.3 Convention to rights of a Child C3.4 CEDAW C3.5 Regional Prevention for Blindness Strategy Page | 46 KRA 3 Objectives To address the KRA priorities and targets and to meet each department’s pre assigned roles and responsibilities, the directorate of Hospital Health Services will seek to implement at least the following objectives. DA 1. Clinical Patient Care Services GOPD/A&E

1.1. Strengthen GOPD services through advanced level training (GP Program) and advanced emergency training.

1.2. Strengthen triaging of patients for early and urgent care of very sick patients.

1.3. Strengthen and embed PEN management for NCD control into patient consultation process.

1.4. Support and strengthen gender violence counselling. Surgery and Anaesthesia

1.5. Support and strengthen existing surgical and anaesthetic services.

1.6. Upgrade surgical services to include interventional endoscopy.

1.7. Strengthening laparoscopy procedures.

1.8. Strengthening orthopaedic innovative procedures relating to fracture management.

1.9. Support Critical Care Nursing for High Dependency Unit staff. Obstetrics and Gynaecology

1.10. Maintain and strengthen current services in obstetrics care and Safe Motherhood.

1.11. Strengthen ANC screening services especially for reproductive tract infection, and PAP smear.

1.12. Support preconception counselling especially in relation to NCD. Medicine

1.13. Support and strengthen current services in medicine and referral services.

1.14. Strengthen cardiac assessment such as angio-vascular risk assessment and diagnostic capabilities such as echocardiogram services and treadmill option.

1.15. Strengthen diagnostic capability through modern medical technology eg. CT Scanner. Paediatrics

1.16. Strengthen paediatrics inpatient and outpatient services.

1.17. Strengthen neonatal care and services.

1.18. Support School based screening programs.

1.19. Initiate and support Baby Friendly Hospital Program and status recognition.

1.20. Support IMCI training and Program especially in the Pa Enua. Ophthalmology

1.21. Strengthen current services provided in eye care including refraction.

1.22. Support awareness and interventions on preventable causes of blindness.

1.23. Provide treatment services for diabetes eye complications.

1.24. Support clinical services for visiting eye specialists.

1.25. Support training for Retinal Mapping provided to staff. Page | 47 DA 2. Medical Referral Services (Domestic and International)

2.1. Support and facilitate cost effective evacuation and referral of patients for overseas medical treatment as per policy.

2.2. Support treatment and management of Pa Enua referred patients through timely interventions.

2.3. Support ongoing treatment and reviews of overseas treated patients.

2.4. Support return treatment, care and follow up of overseas treated patients. DA 3. Specialist Care

3.1. Support the development of local staff as specialist as outlined in the Workforce Development Plan.

3.2. Coordinate and facilitate the scheduled visits of specialist in the various clinical fields.

3.3. Advocate for clinical and technical service support in the various disciplines including diagnostic and biomedical services.

3.4. Coordinate with partner agencies and island governments on specialist visits and services for the Pa Enua.

3.5. Implement funding support for high risk surgical referral cases in New Zealand on long waiting list. KRA 3 Targets Certain priority actions and targets have been selected and included in the monitoring and evaluation framework. DA 1. Clinical Patient Care Services GOPD/A&E

1.1. Reduce by 20% the current (2016) waiting time for patients (less than 99 minutes).

1.2. Reduce patient re-admission rate for the same ailment (Respiratory Asthma and Diabetic Control) within 28 calendar days of discharge.

1.3. Cardio Vascular Risk Assessment of all recommended patients 40 years and over.

1.4. All GOPD patients are processed through triage for early identification and management of urgent cases. Surgery & Anaesthesia

1.5. Perioperative mortality rate (POMR) after 30 days is maintained at Zero.

1.6. Post-operative infection rate (POIR) maintained below 20% of 2016 figures.

1.7. All department nursing staff trained in Critical Care Nursing.

1.8. Introduce interventional endoscopy.

1.9. Best practice (time and outcome) of laparoscopy procedures maintained.

1.10. Pre-operative checklist and consent forms implemented and monitored.

1.11. Qualified anaesthetic assistant nurse, recovery nurse and theatre nurse. Obstetrics & Gynaecology

1.12. Incidence of premature labour and births reduced by 50% from current rate of 2.9%.

1.13. Increase PAP smear screening to cover 80% women in the reproductive age group and beyond (21-65 years).

1.14. Maintain zero maternal mortality.

1.15. Reduce sexually transmitted infection especially chlamydia among the antenatal women. Medicine

1.16. Cardiac echo cardiogram undertaken on all (100%) patients recommended for screening. Page | 48

1.17. Introduce treadmill stress test assessment capability.

1.18. Rheumatic Heart Disease Register established.

1.19. Minimise the number of treatment refusals for rheumatic heart cases.

1.20. Increase compliance to rheumatic heart disease prophylaxis treatment from 2016 level.

1.21. Reduce myocardial infarction by 5%.

1.22. Reduce cerebrovascular accidents by 5%.

1.23. Reduce end stage renal failure by 5%. Paediatrics

1.24. Rarotonga Hospital declared Baby Friendly Hospital.

1.25. All Paediatric nursing staff/ midwives trained in neonatal resuscitation.

1.26. Developmental milestones assessed on all children from birth to five years (birth, 6 weeks, 3 months, 6 months, 1 year, before Early childhood education).

1.27. Follow up of all babies born to all hepatitis B mothers between 9 months and 12 months. Ophthalmology

1.28. Diabetic retinopathy data base established and maintained.

1.29. Annual outreach Program implemented.

1.30. Preventable blindness cases identified and managed (i.e. infection, diabetic, cataract, accidental).

1.31. Recommended cases managed for refraction. DA 2. Medical Referral Services

2.1. Reduce number of chartered flights to the Pa Enua from 2016 level.

2.2. Reduced number of referrals to Rarotonga and New Zealand from 2016 level.

2.3. Reduce the number of complaints in regards to the referral and transfer processes.

2.4. Improve on number of follow ups from referral cases and the number that can be managed in country.

2.5. Improve on number of certified medical and nursing escorts. DA 3. Specialist Care

3.1. At least 12 HSV programs implemented yearly.

3.2. Establish a Radiologist service with Middlemore Hospital to report on all x-ray images from the Cook Islands.

3.3. Establish eligibility criteria for high risk orthopaedic cases to prioritise funding of one case per year (total hip replacement and knee replacement surgeries). Page | 49 Key Result Area 4: Allied Health Services Department Aligned Hospital Health Services A. Policy Goal: To provide high quality pharmaceutical service, diagnostics and support services to meet clinical care patients and the communities in line with the policies and resources of the Ministry. B. Delivery Areas (DA): Delivery Area 1: Pharmacy Delivery Area 2: Radiology Delivery Area 3: Laboratory Delivery Area 4: Physiotherapy/Occupational Therapy Delivery Area 5: Biomedical Delivery Area 6: Ambulance/Paramedics Delivery Area 7: Dietary Services C. Policies and Planning Strategies Linked to KRA The following specific plans are in existence and have been considered in the planning process of the KRA. C1. Program Specific Plans C1.1 National Laboratory Policy C1.2 Strategic Plan for Laboratory Services C1.3 Radiology Plan; C1.4 Pharmacy Quality Assurance and Standard Operating Procedure C1.5 Antibiotic Guidelines C1.6 Mental Health and Well Being Strategy 2016 – 2019 C2. Sector-wide Policies and Planning Strategies Linked to KRA C2.1 Elderly and Disability Policy (INTAFF Rauti Para Policy) C2.2 Road Safety Strategy 2020 – 2025 C2.3 Pharmaceutical and Therapeutics Products Regulation 2014 C2.4 NCD Strategy 2015 – 2019 C2.5 National Action plan for Antimicrobial Resistance C2.6 Cook Islands Health Workforce Plan 2016 – 2020 C2.7 Cook Islands Mental Health and Wellbeing Policy C3. Regional / Global Strategies C3.1 Healthy Islands Strategy and Vision C3.2 Regional Strategy for NCD C3.3 International Health Regulations C3.3 Convention on the rights of a Child Page | 50 KRA 4 Objectives DA 1. Pharmacy

1.1. Support and strengthen pharmaceutical services through the provision of resources (human, financial and equipment) to meet basic pharmaceutical needs and store management.

1.2. Have available for use a regular supply of medicines at favorable prices and that meets recognized standards of quality.

1.3. Review and update existing treatment guidelines, essential medicine list and national medicine policy.

1.4. Strengthen optimal use of medicines through improved clinical support. DA 2. Physiotherapy/Occupational Therapy

2.1. Provide and strengthen physiotherapy services to cater for expanding patient health care needs.

2.2. Strengthen rehabilitation Program including training and networking.

2.3. Scope the provision of hydrotherapy facility and service at Rarotonga Hospital. DA 3. Laboratory

3.1. Maintain and strengthen current services in haematology, biochemistry, microbiology, blood Bank, overseas lab tests referrals and related services in the laboratory.

3.2. Capacity building and institutional strengthening to full ISO standard.

3.3. Strengthen electronic laboratory information system through scoping of relevant system and training of staff for improved surveillance and reporting. DA 4. Radiology

4.1. Maintain and strengthen current radiologic diagnostic services.

4.2. Support human resource development for upgraded services.

4.3. Introduce echo cardiogram and strengthen fluoroscopy diagnostic capability.

4.4. Strengthen radiologic and scanning services to also cater for outreach services to Aitutaki. DA 5. Biomedical

5.1. Update baseline minimum equipment requirement in all sections and service units of the hospital.

5.2. Strengthen management of medical equipment especially the identification, verification, procurement, servicing and disposal.

5.3. Undertake standards and policy formulation to address biomedical equipment management (including the oxygen plant). DA 6. Ambulance/Paramedic Service

6.1. Manage and strengthen ambulance and emergency patient transportation service.

6.2. Building staff capacity and capability within the ambulance service. DA 7. Dietary Service

7.1. Manage and strengthen dietary services in the Hospital and dietary clinic. KRA 4 Targets Certain priority actions and targets have been selected and included in the monitoring and evaluation framework. DA 1. Pharmacy

1.1. Acquire and operate a new ICT system that improves on the existing Toniq system. Page | 51

1.2. Nil Stock out for NCD (Diabetes, Hypertension) medications.

1.3. Drug and therapeutic committee quarterly meetings maintained and reported.

1.4. Essential Medicine list reviewed every two years and align to Anti-Microbial Resistance Action Plan and Antibiotic guidelines. DA 2. Physiotherapy/Occupational Therapy

2.1. Explore alternatives for hydrotherapy facilities and services.

2.2. Certified ultrasound training service for musculo-skeletal cases completed.

2.3. Number of disabled patients attended to in the hospital or community setting. DA 3. Laboratory

3.1. Assess and report on best options for Laboratory Information System software (LIS).

3.2. Maintain quality assurance laboratory standards.

3.3. Unqualified audit report for laboratory inventory yearly. DA 4. Radiology

4.1. Radiology Service Plan Formulated by 2021.

4.2. Develop a Radiology Equipment management policy.

4.3. Scope radiology capabilities in Aitutaki hospital. DA 5. Biomedical

5.1. Medical Equipment Donation Policy developed.

5.2. Medical Asset Management Policy developed.

5.3. Oxygen Plant Management Plan developed. DA 6. Ambulance/ Paramedics services

6.1. Ambulance dispatch time maintained at 3 minutes.

6.2. Advance level care delivered to all patients.

6.3. Establish a voluntary support service for ambulance officers/paramedics. DA 7. Dietary Services

7.1. Develop menu plans for inpatients.

7.2. Dietary counselling services offered for all non-compliant cases. Page | 52 Key Result Area 5: Pa Enua Health Services Department Aligned All Directorates A. Policy Goal: To strengthen Pa Enua Health Services and improve participation in national health care service agenda especially on primary health care and healthy islands initiatives. B. Delivery Areas (DA): Delivery Area 1: Community Health Services Delivery Area 2: Hospital Health Services C. Policies and Planning Strategies Linked to KRA The following specific plans are in existence and have been considered in the planning process of the KRA: C1. Program Specific Strategies and Plans C1.1 Islands specific Strategic Plans C1.2 National Strategic Plan for Sexual and Reproductive Health Strategy 2014-2018 C1.3 National Strategy for NCD 2015-2019 C1.4 Tobacco Action Plan 2012-2016 C1.5 National Immunisation Policy C1.6 National Deworming Policy 2015 C1.7 Oral Health Strategic Plan 2014-2018 C1.8 Mental health and well-being strategy 2016-2021 C1.9 Suicide prevention Strategy 2016-2021 C2. Sector-wide Policies and Planning Strategies Linked to KRA C2.1 Road Safety Strategy 2016 – 2020 C2.2 Sanitation (Wastewater Management) Policy 2016 C2.3 National Water Policy (TBC) C2.4 Infection Control policy C2.5 National action plan on Anti-Microbial resistance. C2.6 Elderly and Disability Policy (INTAFF Rauti Para Policy) C3. Regional / Global Strategies C3.1 Healthy Islands Strategy and Vision C3.2 Regional Strategy for NCD C3.3 International Health Regulation C3.4 Community Based Rehabilitation guidelines C3.5 Suva Declaration on improving oral health in the Pacific Islands Region Page | 53 KRA 5 Objectives Based on available resources, the strategic objectives are operationalised yearly through the TMO Business Plan. The Business Plan will itemise the activities linked to the strategic objective. DA 1. Community Health Services

1.1. Strengthen and support implementation of primary health care activities especially on disease control.

1.2. Strengthen and support maternal and reproductive health services.

1.3. Strengthen child health services especially on immunisation and nutrition Programs.

1.4. Support health promotion and health protection activities at the Pa Enua level.

1.5. Strengthen disease surveillance and health service monitoring and reporting.

1.6. Strengthen domiciliary and chronic disease screening, cases follow up and management.

1.7. Strengthen environment health monitoring especially in relation to vector, safe water, proper sanitation and waste management.

1.8. Strengthen and support implementation of oral health preventative and specialist services.

1.9. Support research activities in health communication.

1.10. Strengthen IEC material production and dissemination. DA 2. Hospital Health Services

2.1. Strengthen PEN management for NCD control.

2.2. Support and strengthen gender violence counselling.

2.3. Support and strengthen current services in medicine and referral services.

2.4. Initiate and support Baby Friendly Hospital program and status recognition.

2.5. Maintain and strengthen current services in obstetrics care and Safe Motherhood.

2.6. Strengthen ANC screening services especially for reproductive tract infection, and PAP smear.

2.7. Support awareness and interventions on preventable causes of blindness.

2.8. Support and strengthen ongoing clinical service in Pa Enua hospitals and health stations.

2.9. Introduce IMCI training for all staff.

2.10. Introduce the Baby Friendly Hospital Initiative for Aitutaki.

2.11. Support ongoing skill training for all medical staff.

2.12. Regular ongoing support from the Chief Nursing Officer and Chief Medical Officer on all clinical issues and professional programs.

2.13. Coordinate and facilitate the scheduled visits of specialist in the various clinical fields. Page | 54 KRA 5 Targets Certain priority targets have been selected and included in the monitoring and evaluation framework. DA 1. Community Health Services

1.1. Completed (100%) health profile of each Pa Enua (demography, health and wellbeing). 1.2. 40% of all private dwellings on Aitutaki inspected, assessed and meet the Sewage Regulation 2014. 1.3. 50% commercial properties on Aitutaki comply with the Sewage Regulation 2014.

1.4. Reduce smoking by 20% of current level of smokers.

1.5. Achieve 100% DOTS coverage (TB).

1.6. Minimise the number of treatment refusals for rheumatic heart cases.

1.7. Increase compliance to rheumatic heart disease prophylaxis treatment.

1.8. Improve measles vaccine coverage to 98%.

1.9. Establish exclusive breastfeeding rate on discharge from birth 3months and 6months.

1.10. Complete all school physical health examination (2yearly).

1.11. Pre-schoolers and Primary oral health preventive Program established in 100% of schools.

1.12. Identify and register all patients with a mental health illness.

1.13. Number of mental health patients referred for counselling or treatment.

1.14. Less than 10 complaints received for non-compliance to Food Act and Regulations.

1.15. Less than 10 complaints received for water borne related illnesses.

1.16. Maintain zero vector borne cases.

1.17. Register number/type of toilets in private dwellings.

1.18. Community Health Services Geographic Information System established. DA 2. Hospital Health Services

2.1. Cardio Vascular Risk Assessment of all recommended patients 40 years and over.

2.2. Incidence of premature labor and births reduced by 50% from current rate of 2.9%.

2.3. Increase PAP smear screening to cover 80% women in the reproductive age group and beyond (21-65 years).

2.4. Integrated Management of Childhood Illnesses introduced to all Pa Enua stations.

2.5. Aitutaki Hospital declared Baby Friendly Hospital by 2021.

2.6. Medical equipment and assets maintained and updated annually.

2.7. Reduction by 30% from the mean dmft 6.6 in 5 years old.

2.8. Reduction by 30% in tooth decay prevalence in Primary Schools (80%).

2.9. Reduction by 30% in the mean DMFT (7.3, 12.9 and 21.9) of the adult population of WHO indexed age groups.

2.10. Receive scoping report of radiology capabilities on Aitutaki and implement relevant recommendations.

2.11. Nil Stock out for essential medicines especially NCD (Diabetes, Hypertension) medications.

2.12. Pa Enua health centres/residences at Atiu, Mangaia, Mauke and Pukapuka refurbished to appropriate standards.

2.13. Renovation of Aitutaki Hospital completed. Page | 55 Key Result Area 6: Health Partners Department Aligned All Directorates A. Policy Goal: To work collaboratively to complement and support health partners in the implementation of agreed health related interventions and activities. B. Partnership Areas: Partnership Area 1: Government Agencies Partnership Area 2: Civil Society and Non-Government Organisations Partnership Area 3: Development Partners C. Partners Policies and Planning Strategies Linked to Health C1. Education  Inclusive Education Policy  Education Master Plan 2008 - 2023 C2. Internal Affairs  CI National Youth Policy 2015-2020  CI Disability Inclusive Development Policy Action Plan 2014-2019  Family Law Bill  CI Policy on Ageing (Rauti Para) 2012-2017  CI National Policy on Gender Equality and Women's Empowerment & Strategic Plan of Action 2011- 2016  Suicide Prevention Strategy 2016-2021  Pension, destitute and infirm benefits welfare system  Convention for the Elimination of Domestic violence Against Women (CEDAW) C3. Public Service Commission  Public Sector Strategy 2016-2025  Public Service Act 2009 C4. Agriculture  Food and Agriculture Sector Master Plan 2030  Codex Alimentarius  Biosecurity Page | 56 C5. Police  Cook Islands Road Safety Strategy 2015-2020  Crimes Act 1969 and Amendments  Transport Act 1966 and Amendments  Cook Islands Family Health and Safety Survey 2014  Narcotics and Misuse of Drugs Act 2004 C6. Infrastructure Cook Islands  CI Solid Waste Management Policy 2016-2026  CI Sanitation (Wastewater Management) Policy 2016  CI National Infrastructure Investment Plan  National Water Policy  Building Code  Road Master Plan C6. Emergency Management Cook Islands  Cook Islands Disaster Risk Management Act 2007 C7. CI Child Welfare Association  CI Child Welfare Association Constitution C8. CI Family Welfare Association  CI Integrated Sexual and Reproductive Health Strategy 2014-2018 C9. Te Kainga  Mental Health and Well Being Policy 2015  Mental Health and Well-Being Strategy 2016-2021  Suicide Prevention Strategy 2016-2021 C10. Te Vaerua  Disability Inclusive Development Policy and Action Plan 2014 – 2019 C11. Mens Rota’ianga  CI Integrated Sexual and Reproductive Health Strategy 2014-2018 C12. CI National Disability Council  Disability Inclusive Development Policy and Action Plan 2014 – 2019  Disability Act 2008 C 13. CI National Council of women  Family law Bill  Family health and Safety Survey Page | 57  Convention for the Elimination of Domestic violence Against Women (CEDAW)  CI National Policy on Gender Equality and Women's Empowerment & Strategic Plan of Action 2011- 2016 C 15. WHO  Statement of intent  Cook Islands country cooperation Strategy (CCS) C 16. UNFPA  Statement of intent C 17. UNICEF  Statement of intent C 18. UNDP/GLOBAL FUND  Statement of intent C 19. NZ MFAT  Statement of intent C 20. SPC  Statement of intent KRA 6 Objectives The following local health partners are recognized for their contribution to the health service and community based health care and programs for citizens. The Ministry of Health will seek to support the contribution of the partners through the following stated joint strategies. In relation to networking, overseas partnership with professional bodies and specialist services are also recognized. Any specific targets / objectives needing funding are linked back to KRA 1-5. 1. Government Agencies Education

1.1. Partnership with CITTI towards establishment of tertiary Nursing and Health Faculty

1.2. Support school health activities especially on the coordination of school visitations

1.3. Support health promotion settings approach for school health Internal Affairs

1.4. Support community based rehabilitation and care.

1.5. Contribute to the development and implementation of social policies to improve the lives of the vulnerable children, young people and their families, elderly people and people with disabilities and women. Page | 58 Agriculture

1.6. Support food security initiatives to mitigate for disaster and climate change

1.7. Support initiatives on ensuring nutrition values of agriculture produce including organic farming practices.

1.8. Ensure food standards (including Codex) as outlined in legislation are maintained.

1.9. Support health quarantine and biosecurity requirements. Public Service Commission

1.10. Support human resource development – training and performance assessment

1.11. Support sector wide service excellence in the Ministry. Finance and Economic Management

1.12. Support and implementing budget policies Police

1.13. Support strategies to eliminate domestic violence.

1.14. Support initiatives and Programs on suicide prevention.

1.15. Support monitoring, enforcement and reporting of motor vehicle crashes.

1.16. Support coroner investigations. Justice

1.17. Register all births and deaths.

1.18. Support coroner investigations.

1.19. Support for highly aggressive and violent mental health cases. Crown law

1.20. Providing legal opinion on health issues. Foreign Affairs and Immigration

1.21. Support with medical clearance processes for contract workers. 2. Civil Society and Non-Government Organisations Red Cross

1.22. Support National Blood Transfusion Committee and RC on blood donation / collection for emergencies.

1.23. Support community capacity building on disaster awareness and mitigation.

1.24. Strengthen community-based health and first aid (CBHFA) training. Te Vaerua

1.25. Support and strengthen rehabilitation services. CI Child Welfare Association Page | 59

1.26. Facilitate and support services from maternal and child welfare clinics. CI Family Welfare Association

1.27. Support the expanding range of SRHR services in the Cook Islands that includes family planning (FP), HIV Prevention and STI Treatment including Voluntary Confidentiality Counselling.

1.28. Support screening program for breast and cervical and other gynecological disorders. CI National Disability Council

1.29. Support health awareness activities and interventions. CI National Council of women

1.30. Support health awareness activities and interventions. Te Kainga O Pa Taunga

1.31. Support the role of Te Kainga O Pa Taunga particularly in community mental health services.

1.32. Facilitate process for compensation for Te Kainga O Pa Taunga patients in respite care. Punanga Tauturu

1.33. Support awareness activities and interventions on domestic violence. Mens Rota’ianga

1.34. Support awareness activities on men’s health particularly screening activities against prostate cancer.

1.35. Support awareness activities in reproductive health for men especially the use of male method of family planning. Development partners

1.36. Support the implementation of the Te Papa Tutara A Te Marae Ora 2017-2036 (“Health Roadmap)” and Takai’anga Angaanga Tutara A Te Marae Ora 2017-2021 (“National Health Strategy”). KRA 6 Targets Partnership is fostered in all priority areas. Certain priority actions and targets have been selected and included in the monitoring and evaluation framework. Education a. Establishment of tertiary Nursing and Health Training School. b. Biennial school health reports. Internal Affairs a. Register of certified trained Care Givers. b. Annual report received on the vulnerable groups youth, disable (mental and physical), elderly. Page | 60 Agriculture a. Register of schools with “home gardens”. b. Increased number of local farmers. Public Service Commission a. Excellence award recipient. Finance and Economic Management a. Support funding options for social health insurance for all government employees with possibility of extension to private sector employees. Cook Islands Audit Office a. Carry out auditing of the Ministry of Health. Police a. No drop policy for domestic violence enforced. b. Improved enforcement of drink driving testing / restriction. c. Enforcement of amendments to the Transport Act 1966. Justice a. Register all births and deaths. b. Support coroner investigations. c. Support for highly aggressive and violent mental health cases. Crown law a. Providing legal opinion on health issues. Foreign Affairs and Immigration a. Support with medical clearance processes for contract workers. Punanga Tauturu a. Provide counselling and support for victims CI Child Welfare Association a. Service MOU established between TMO and CWA. b. Number of functioning maternal and child welfare clinics CI Family Welfare Association a. Contraceptive prevalence increased to 35% b. Increase Pap smear screening to cover 80% women in the reproductive age group. Page | 61 Mens Rota’ianga a. Support screening for prostate cancer undertaken annually. b. Advocacy for male methods of FP (vasectomy) and improved coverage overall. CI Red Cross a. Number of training provided for disaster risk management and CBHFA Te Vaerua a. Number of rehabilitative cases by sex and age. Development Partners a. Health specific plans implemented. Page | 62 Implementing Structure and Schedule Achievement of the targets of the NHSP 2017-2021 will be at least dependent on resource allocation, staff availability and implementation mechanism. The Key Result Areas and the accompanying strategies and objectives are aligned to the organisational structure of the Ministry for ownership. Under each organisation directorate, a health Director is responsible for the supervision and management of the division. Implementation of the key result area, strategies and objectives will be under each Director’s responsibility guided by Annual Business Plans. Table 7: Implementing Structure and Schedule Organisation Structure / Program Key Result Area Officer Responsible Unit KRA 1: Health Administration Administration and Management Director Funding and Planning and Management KRA 2: Community Health Director Community Health Community Health Service Services Services Director of Hospital Health KRA 3: Hospital Health Services Hospital Health Service Services Director of Hospital Health KRA 4: Allied Health Hospital Health Services Services Chief Medical Officer/Chief KRA 5: Pa Enua Health Services Hospital Health services Nursing Officer HOMs of Government, Partners KRA 6: Health Partners All related and aligned Departments and NGOs. At TMO, HOD of aligned program / interventions. Noting that budget and funding allocations are also aligned to the structure, monitoring of activities implementation and challenges faced will be the responsibility of the line Directors. Page | 63 Costing the Health Strategy The following tabulation lists the additional requirements in health budgetary provision to support the NHSP implementation. It must be noted that current provision under the government financial system and funding categories are important as it supports the key functions of the Ministry. Funding requests identified under the Objectives are special and additional to normal funding provisions. These funding requests are summarised as additional cost requirements for NHSP implementation. KRA 1: Health Administration and Management Goal: To strengthened administrative and management capacity and capability to meet the health systems and health service needs, demands and expectations for the Ministry of Health. Estimated Annual Budget Requirement Delivery Areas KRA 2017 2018 2019 2020 2021 Objectives Leadership and 1.1 Existing Existing Existing Existing Existing Governance 1.2 Existing Existing Existing Existing Existing 1.3 Existing Existing Existing Existing Existing 1.4 Existing Existing Existing Existing Existing 1.5 60,000 30,000 60,000 30,000 30,000 1.6 Existing Existing Existing Existing Existing Health Finance 2.1 Existing Existing Existing Existing Existing 2.2 Existing Existing Existing Existing Existing Page | 64 2.3 Existing Existing Existing Existing Existing

2.4 Existing Existing Existing Existing Existing 2.5 10,000 Human Resource 3.1 Development 90,000 90,000 50,000 50,000 50,000 3.2 50,000 50,000 50,000 50,000 50,000 3.3 10,000 10,000 10,000 10,000 10,000 3.4 20,000 20,000 20,000 20,000 20,000 Health Information 4.1 Existing Existing Existing Existing Existing 4.2 Existing Existing Existing Existing Existing 4.3 Existing Existing Existing Existing Existing 4.4 Existing Existing Existing Existing Existing

4.5 Existing Existing Existing Existing Existing 4.6 30,000 10,000 10,000 10,000 10,000 Page | 65 Health Research & 5.1 Existing Existing Existing Existing Existing Policy 5.2 5,000 65,000 Existing Existing Existing Health 6.1 Existing Existing Existing Existing Existing Infrastructure

6.2 Existing Existing Existing Existing Existing

6.3 Existing Existing Existing Existing Existing Cost sub-total 265,000 285,000 200,000 170,000 170,000 KRA 2: Community Health Services Goal: To strengthen and improve Community Health Services and community health care services under the principles of Primary Health Care and Healthy Islands context. Estimated Annual Budget Requirement Delivery Areas KRA 2017 2018 2019 2020 2021 Objectives H. Protection 1.1 Existing Existing Existing Existing Existing 1.2 Existing Existing Existing Existing Existing 1.3 120,000 120,000 120,000 120,000 120,000 1.4 Existing Existing Existing Existing Existing 1.5 Existing Existing Existing Existing Existing Page | 66 1.6 Existing Existing Existing Existing Existing 1.7 10,000 10,000 10,000 10,000 10,000 1.8 Existing Existing Existing Existing Existing

1.9 Existing 50000 50000 Existing Existing H. Promotion 2.1 Existing Existing Existing Existing Existing 2.2 Existing Existing Existing Existing Existing 2.3 Existing Existing Existing Existing Existing 2.4 Existing Existing Existing Existing Existing 2.5 Existing Existing Existing Existing Existing 2.6 Existing Existing Existing Existing Existing 2.7 Existing Existing Existing Existing Existing 2.8 Existing Existing Existing Existing Existing

2.9 Existing Existing Existing Existing Existing 2.1 Existing Existing Existing Existing Existing 2.11 10,000 10,000 10,000 10,000 10,000 Page | 67 2.12 Existing Existing Existing Existing Existing 2.13 Existing Existing Existing Existing Existing

2.14 Existing Existing Existing Existing Existing

2.15 Existing Existing Existing Existing Existing

2.16 Existing Existing Existing Existing Existing

2.17 Existing Existing Existing Existing Existing PH Nurses

3.1 Existing Existing Existing Existing Existing 3.2 Existing Existing Existing Existing Existing 3.3 Existing Existing Existing Existing Existing 3.4 Existing Existing Existing Existing Existing

3.5 Existing Existing Existing Existing Existing 3.6 5000 5000 5000 5000 5000

3.7 Existing Existing Existing Existing Existing 3.8 Existing Existing Existing Existing Existing

3.9 Existing Existing Existing Existing Existing 3.1 5,000 Page | 68 5,000 5,000 5,000 5,000 Child Health 3.1 Existing Existing Existing Existing Existing

3.2 Existing Existing Existing Existing Existing

3.3 Existing Existing Existing Existing Existing

3.4 Existing Existing Existing Existing Existing 3.5 5,000 5,000 5,000 5,000 5,000

3.6 Existing Existing Existing Existing Existing RHD 3.7 3,000 3,000 3,000 3,000 3,000

3.8 Existing Existing Existing Existing Existing

3.9 Existing Existing Existing Existing Existing

3.10 Existing Existing Existing Existing Existing

3.11 Existing Existing Existing Existing Existing

3.12 Existing Existing Existing Existing Existing

3.13 Existing Existing Existing Existing Existing

3.14 Existing Existing Existing Existing Existing Page | 69 Oral Health (Dental) 4.1 Existing Existing Existing Existing Existing 4.2 Existing Existing Existing Existing Existing 4.3 Existing Existing Existing Existing Existing

4.4 Existing Existing Existing Existing Existing 4.5 20,000 20,000 20,000 20,000 20,000 Mental Health 5.1 Existing Existing Existing Existing Existing 5.2 30,000 30,000 30,000 40,000 40,000 5.3 Existing Existing Existing Existing Existing

5.6 Existing Existing Existing Existing Existing Cost sub-total 208,000 258,000 258,000 213,000 218,000 Page | 70 KRA 3: Hospital Health Services Goal: To provide high quality clinical care and services to meet the needs and expectations of patients and that are in line with the policies and resources of the Ministry of Health. Estimated Annual Budget Requirement Delivery Areas KRA Objectives 2017 2018 2019 2020 2021 C. Patient Care GOPD / AE 1.1 Existing Existing Existing Existing Existing 1.2 Existing Existing Existing Existing Existing 1.3 Existing Existing Existing Existing Existing 1.4 Existing Existing Existing Existing Existing Surgery & 1.5 Existing Existing Existing Existing Existing Anaesthesia 1.6 Existing Existing Existing Existing Existing

1.7 Existing Existing Existing Existing Existing

1.8 Existing Existing Existing Existing Existing 1.9 30,000 30,000 30,000 30,000 30,000 O&G 1.10 Existing Existing Existing Existing Existing Page | 71 1.11 20,000 20,000 20,000 20,000 20,000

1.12 Existing Existing Existing Existing Existing Medicine 1.13 Existing Existing Existing Existing Existing

1.14 Existing Existing Existing Existing Existing

1.15 Existing Existing Existing Existing Existing Paediatrics 1.16 Existing Existing Existing Existing Existing

1.17 Existing Existing Existing Existing Existing

1.18 Existing Existing Existing Existing Existing 1.19 20,000 20,000 10,000 10,000 10,000

1.20 Existing Existing Existing Existing Existing Ophalmology 1.21 Existing Existing Existing Existing Existing

1.22 Existing Existing Existing Existing Existing

1.23 Existing Existing Existing Existing Existing

1.24 Existing Existing Existing Existing Existing Page | 72

1.25 Existing Existing Existing Existing Existing Medical Referral 2.1 Existing Existing Existing Existing Existing Services 2.2 Existing Existing Existing Existing Existing 2.3 Existing Existing Existing Existing Existing

2.4 Existing Existing Existing Existing Existing

4.1 Existing Existing Existing Existing Existing Specialist Care 4.2 Existing Existing Existing Existing Existing 4.3 Existing Existing Existing Existing Existing 4.4 Existing Existing Existing Existing Existing

4.5 Existing Existing Existing Existing Existing 70,000 70,000 60,000 60,000 60,000 Cost sub-total Page | 73 KRA 4: Allied Health Service Goal: To provide high quality pharmaceutical service, diagnostics and support services to meet clinical care patients and the communities in line with the policies and resources of the Ministry. Estimated Annual Budget Requirement Delivery Areas KRA 2017 2018 2019 2020 2021 Objectives Pharmacy 1.1 100,000 1.2 200,000 200,000 200,000 200,000 200,000 1.3 Existing Existing Existing Existing Existing 1.4 Existing Existing Existing Existing Existing

2.1 Existing Existing Existing Existing Existing Physiotherapy 2.2 Existing Existing Existing Existing Existing

2.3 Existing Existing Existing Existing Existing Laboratory 3.1 Existing Existing Existing Existing Existing 3.2 10,000 10,000 10,000 10,000 10,000 Page | 74

3.3 Existing 20,000 Existing Existing Existing Radiology 4.1 Existing Existing Existing Existing Existing

4.2 Existing Existing Existing Existing Existing

4.3 Existing Existing Existing Existing Existing

4.4 Existing Existing Existing Existing Existing Biomedical 5.1 Existing Existing Existing Existing Existing

5.2 Existing Existing Existing Existing Existing

5.3 Existing Existing Existing Existing Existing Ambulance Service 6.1 Existing Existing Existing Existing Existing

6.2 HR linked HR linked HR linked HR linked HR linked Dietary Service 7.1 Existing Existing Existing Existing Existing Cost sub-total 310,000 230,000 210,000 210,000 210,000 Page | 75 KRA 5: Pa Enua Health Services Goal: To strengthen and improve Community Health Services and community health care services under the principles of Primary Health Care and Healthy Islands context. Goal: To provide high quality clinical care and services to meet the needs and expectations of patients and that are in line with the policies and resources of the Ministry of Health. Estimated Annual Budget Requirement Delivery Areas KRA 2017 2018 2019 2020 2021 Objectives Community Health Care

1.1 Existing Existing Existing Existing Existing

1.2 Existing Existing Existing Existing Existing

1.3 Existing Existing Existing Existing Existing

1.4 Existing Existing Existing Existing Existing

1.5 Existing Existing Existing Existing Existing

1.6 Existing Existing Existing Existing Existing 1.7 50,000 50,000 50,000 50,000 500,000

1.8 Existing Existing Existing Existing Existing

1.9 Existing Existing Existing Existing Existing 1.10 5000 5000 5000 10000 10000 Page | 76 Clinical services 2.1 Existing Existing Existing Existing Existing

2.2 Existing Existing Existing Existing Existing

2.3 Existing Existing Existing Existing Existing 2.4 5,000 5,000 5,000 5,000 5,000

2.5 Existing Existing Existing Existing Existing

2.6 Existing Existing Existing Existing Existing

2.7 Existing Existing Existing Existing Existing

2.8 Existing Existing Existing Existing Existing 2.9 5,000 5,000 5,000 555,000 5,000

2.10 Existing Existing Existing Existing Existing

2.11 Existing Existing Existing Existing Existing

2.12 Existing Existing Existing Existing Existing

2.13 Existing Existing Existing Existing Existing Cost sub-total 65,000 65,000 65,000 620,000 520,000 Page | 77 Table 8: Estimated Summary Budget. 2017 2018 2019 2020 2021 KRA 1: Health Administration 265,000 258,000 200,000 170,000 170,000 and Management KRA 2: Community Health 208,000 258,000 258,000 213,000 218,000 Services KRA 3: Hospital Health 70,000 70,000 60,000 60,000 60,000 Services KRA 4: Allied Health Service 310,000 230,000 210,000 210,000 210,000 KRA 5: Pa Enua Health 65,000 65,000 65,000 620,000 520,000 Services KRA 6: Health Partners Existing Existing Existing Existing Existing TOTAL $ $ $ $ $ $ 918,000 881,000 793,000 1,273,000 1,178,000 5,043,000 Page | 78 Monitoring and Evaluation Introduction The monitoring and evaluation component of the NHSP is based on a logical framework and addresses a selection of a core set of indicators; identifies the data sources for each indicator; conducting analysis, communication, and dissemination of the results. Monitoring will be used as means of collating data from all relevant sources for analysis and will use the stated set of core indicators and targets to provide timely and accurate information to governments and partners. Evaluation builds upon the monitoring data but the analysis goes much deeper, taking into account contextual changes, addressing questions of attribution, and looking at counterfactual situations. M&E of the NHSP is implemented in parallel to TMO’s health information system and where it derives information from. In addition, Te Marae Ora’s Health Information system has developed a core set of 20 health indicators for use by the Ministry. The indicators set which list processes, outcomes and impacts indicators is used or aligned in the NHSP. Te Marae Ora’s NHSP Indicators Generally, health indicators are numerous and could be difficult to collect, interpret and often do not meet basic quality criteria of relevance, reliability and validity. In the context of the NHSP it is a major challenge to select a core set of indicators that can objectively and effectively monitor progress towards the most important objectives. Whilst there is no optimal number of core indicators, experiences suggest that for national, high-level strategic decision-making the total number of indicators should not exceed 25. It is important to keep in mind that quantitative indicators are intended to be indicative of reality, i.e. they are tracer indicators and they are not intended to describe the totality of what is happening. Target-setting is linked to the various Program specific strategies of Te Marae Ora and aligned to the international targets of the Sustainable Development Goals (SDGs) and regional targets for Healthy Islands. For these reasons the NHSP has both national targets, regional and international health targets aligned. Disease / Program Specific Indicators Most health program area and management units have their own strategic or a plan of action. NCD, Human Resource workforce Plan and HIS Strategies are examples of such action plans. In disease-specific programs, their strategies and operational plans are more detailed than what is outlined the NHSP and with more disease-specific indicators to measure process, outputs and immediate outcomes. In this NHSP, attempts have been made to align the main disease program indicators to the outcome and impact indicators of the M&E component of the NHS so as to demonstrate the effects of health system strengthening to health outcomes. Page | 79 Measurement and Reporting Frequency A certain degree of flexibility can be introduced in the periodicity of data collection for the core indicators. The frequency of measurement and reporting needs are specified below. Input and output indicators can change rapidly and should be measured frequently (at least Yearly annually), in conjunction with monitoring of annual operational plans. 2 yearly Outcome indicators – intervention coverage and selected risk behaviors – should be reported every two years, though they may be reported annually if rapid changes are expected and appropriate measurement systems are available. Impact indicators should be reported once or twice every five years, which is the average duration of a national health strategy. This longer interval reflects the fact that changes in 5 Yearly impact do not occur rapidly, and measurement is more complex and often based on recall of events. Data Integration with Health Information System Generally all good NHSP monitoring and evaluation framework should be linked with the national health information system (HIS) strategy and plan. A HIS strategy is broader than a monitoring and evaluation strategy, as it should cover all details of the institutional requirements and procedures required of the different producers and users of health information system. It should also include the role of information and communication technology. The capability of the HIS is considered in this NHSP and its role mandated in the coordinating committee for M&E. Moreover, the TMO through the Health Information Unit have undertaken an inclusive process bringing together key decision-makers across disease-focused and system-specific programs to formulate and agree on set of core indicators for TMO. These indicators are included in the tables below. Page | 80 Ministry of Health 20 Key Health Indicators The following set of indicators was selected by the Ministry of Health following a consultative process through the assistance of WHO and Queensland University. The indicators are those that could be collected, analysed and reported by the MedTech34 software maintained by the Health Information Unit. Table 9: Te Marae Ora Health Indicators Indicator Use in NHSP No. INDICATOR PURPOSE (Definition) 2017-2021 1 Total Fertility The average number of children that would be born No set target for TFR but Rate(TFR) alive to a woman during their lifetime, if they were to CPR and Teen Pregnancies pass through their childbearing years conforming to used as proxy indicator for (current) age-specific fertility rates of a given year. The fertility. TFR sums up, in a single number, the fertility of all women at a given point in time 2 Number of Births The number of live births in a given year by island of No set target on the (by Island) usual residence of the mother number of births by island. 3 Immunization Percent of targeted population immunized in a given Coverage (overall) year (for children under 5). Summary measure of total immunization coverage for: BCG, DTP3, Polio3, Measured by Measles Measles/Rubella and Tetanus Vaccine coverage. 4 Crude Death Rate The number of deaths per 1,000 population in a given No set target on death rate (CDR) year but reduction in NCD death rate quoted. 5 Top 10 causes of The top ten causes of death (calculated as a percent of No set target on top 10 death (by age all deaths) by sex and age group (five-year age bands) cases of death but NCD group and sex) targeted 6 Infant Mortality Indicator refers to number of infant deaths No set target as IMR (babies/children less than 1 year of age) per 1,000 live currently zero. birth during specific time period Page | 81 Indicator Use in NHSP No. INDICATOR PURPOSE (Definition) 2017-2021 7 Life Expectancy at Describes the number of years person can expect to live No set target. Long term Birth (at time of birth), if they experienced mortality measurement. (Male/Female) conditions prevailing at the time. 8 Top 10 causes of The top ten causes of morbidity (calculated as a percent No set target but general morbidity (by age of all morbid cases registered) by sex and age group morbidity reduction group and sex) (five-year age bands). especially for NCD. 9 Top 5 Notifiable Indicates burden of the Notifiable Diseases – Anthrax, No set target for notifiable Disease Asthma, Bronchitis, Cholera, Chickenpox, Conjunctivitis, diseases but general Dengue, Diarrhea, Fish poisoning (ciguatera), Food reduction in disease poisoning, Otitis media, Influenza, Pneumonia, incidence for RHD, food Rheumatic fever, Scabies, Skin sepsis. Expressed as a poisoning etc percentage of all Notifiable Diseases in a given year. 10 Vaccine Indicates burden of these conditions – Diphtheria, No target set for VPD as preventable Hepatitis B, Measles, Mumps, Poliomyelitis, Tetanus, incidence is low. conditions Tuberculosis (TB), Whooping cough (Pertussis). (incidence) 11 Maternal Deaths The number of maternal deaths (complications of No target set as MMR is pregnancy & childbirth) related to childbearing divided zero. by the number of live births in that year. 12 Number of Proportion (%) of tests that are positive for HIV/AIDS No target for HIV but positive tests for and certain STIs (Chlamydia, Gonorrhoea, Syphilis, Chlamydia incidence set for HIV/AIDS and STIs Trichomonas, Candidiasis), by sex and age group (five- STI. (by sex and age year age bands) group) 13 Domestic Patient Number of cases referred from the Pa Enua to No set target for number of Referrals Rarotonga (by sex and age group) referrals. 14 International Number of cases referred from Rarotonga to New No set target for number of Patient Referrals Zealand (by sex and age group) referrals. 15 Number of Health Indication of service coverage by various types of health No set target for HR. Professionals per providers. Health professionals to include: doctors, Current staff ratios are Page | 82 Indicator Use in NHSP No. INDICATOR PURPOSE (Definition) 2017-2021 1,000 population nurses and allied health. good. (by island) 16 Number of Number of patients admitted in the Cook Islands in a No set target for Inpatients (by sex given year by sex (male/female) and age group (five- admissions. and age group) year bands) and each island 17 Number of Number of outpatient consultations in the Cook Islands No set target on outpatient consultations in a given year by sex (male/female) and age group numbers. using Outpatient (five-year bands). services (by sex and age group) 18 Total health Indicator of the amount of money allocated to health. Indicator for GDP used. budget as a Expressed as a percentage of GDP. percent of GDP 19 Number of Mental Number of mental disorder patients in the Cook Islands No set figure or level but Disorders (by sex in a given year by sex (male/female) and age group prevalence survey and age-group) (five-year bands) and island. targeted. 20 Top 5 causes for The top five causes of dental consultations (calculated Set target for DMFT Dental as a percent of all consultations) by sex (male/female) Consultations (by and age group (five-year age bands) sex and age group) Page | 83 NHSP 2017-2021 Target Indicators Framework The following tables outline the NHSP target indicators by classification, definition and data sources. The tables are also laid out under KRAs and could be used for M&E activities including evaluation of the NHSP. KRA 1 Targets Indicator DEFINITION / DATA SOURCE TARGET FOCUS Type DESCRIPTION (verification) Leadership and Governance 1 Public Health Act 2004 Output Review of existing PH Parliamentary Governance revised by 2021 Act 2004 Brief /TMO 2 Formalized enforcement Output Enforcement Parliamentary Governance regime established Regulation for related Brief / TMO health legislation formulated. 3 Review and formulate Output Formulation of Sewage Parliamentary Governance standards for sewage & Reticulation Brief / TMO / reticulation systems Standards Standards 4 Nursing Clinical Guideline Output Review and update of TMO Governance Nursing Clinical / Guideline Standards 5 Doctors Clinical Guidelines Output Review and update of TMO Governance/ Doctors Clinical Guideline standards Health finance Page | 84 1 Improve general Input Level of general Government Financing government expenditure government expenditure Annual on health as a % of GDP on health (GGHE) Budget SDG9 (5%) expressed as a Appropriation percentage of GDP. 2 Unqualified Financial audit Output Audit report Audit report Financing report obtained undertaken and submitted to reported executive 3 Feasibility study for health Output Conduct of feasibility Report tabled Financing finance options study on health with TMO financing options Executive SDG Health Resources for health and human resources development 1 Health workers per 1 000 Impact The number of health Routine Human workers (doctor, administrative Population. nurse/ midwife) Resources country relative to the records; (Doctor, nurse/ midwife; total Population census; facility SDG urban–rural) assessments 2. Nurse Practitioners Output Establishment of NP Training Human training Program training Program. Report resource established 3. Nursing bachelor degree Output Establishment of Training Human completion training Bachelor degree Report resource Program established with upgrading Program NZ Polytec with NZ Polytec 9 Sustainable Development Goal Page | 85 4. Training for new Pharmacy Output Establishment of Training Human Technicians completed Pharmacy technician Report resource training Program 5. POLHN training for 20 Output POLHN training Training Human staff in the various cadre strengthened with Report resource staff enrolled. WHO Health Information Integrated ‘data warehouse’ Output Creation of software and created and functional at the data storage and sharing Health 1. national level. capability. TMO Report Information Training on proper death Output certification to all medical officers and nurse practitioners and ICD 10 coder ICD coding for death Health 2. training by HIU certifying by HIU staff. TMO Report Information Page | 86 Health Research Health research plan Output Priority areas of research 1. formulated by 2018 identified and planned. TMO Report Research Conduct / facilitate anaemia Output Research prevalence survey in ante- Anaemia survey in AN 10 2. natal women by 2018. mothers Research report. UNICEF Health Infrastructure 1. Health facilities per 10 Impact The number of health National Access 000 Population facilities per databases of population. health facilities 2. Hospital beds per 1000 Impact Hospital beds per 1, National Access pop 000 population databases of health facilities 10 UNICEF (Maternal and Child Health Indicators) Page | 87 KRA 2 Targets INDICATOR DATA SOURCES TARGET DEFINITION / DESCRIPTION TOPIC TYPE (Verification) DA 1. Health Protection 40% of private dwellings % of private dwelling Surveillance / 1. inspected to meet Sewage Output TMO Report meeting SR 2014 Compliance Regulation 2014 50% of commercial % of commercial property Surveillance / 2 properties meeting Sewage Output TMO Report meeting SR 2014 Compliance Regulation 2014 Community health services Establishing a GIS System for Surveillance / 3. geographic information Output TMO Report community health service Compliance system established At least 10 staff undertake and complete Pacific Data Staff trained to undertake 4. Output TMO Report Research for Decision Making (DDM) DDM Training program. DA 2. Health Promotion Reduce premature mortality TMO Report NCD number by year by 11 1 due to NCD by 20% (4% per Impact NCD previous year number in % year) by 2020 STEPS Survey 2 Impact NCD Reduce or maintain school Obesity number by year by School health 11 National NCD strategy 2015-2019/NCD (Pacific MANA/WHO global NCD Monitoring Framework). Page | 88 student obesity rate at 25% previous year number in % survey TMO Report Reduce smoking by 20% of Difference in percentage of 4. Impact Tobacco Control current level of smokers smokers in 2016 and 2021. STEP Survey Amending the Tobacco Enactment of amendments Controls Act to align with Parliamentary 5. to the Tobacco Controls Act Output Tobacco Control certain provisions of the paper 2007 FCTC Tobacco Free Ministry of Ministry publicly declared Ministry 6. Impact Tobacco Control Health by 2021 Tobacco Free Declaration Percentage of premises TMO report (Restaurants, Total number that are non- nightclubs/bars, public compliant as a percentage 7. Output / Impact Surveillance / Tobacco Control places) compliant with of the total number of Enforcement Current Tobacco Control premises. Report Laws Declare 1 island as Tobacco 1 Island publicly declared 8. Impact Public declaration Tobacco Control Free Tobacco free 9. Maintain zero HIV Impact HIV incidence Health Statistics STI/ HIV Increase by 30% Percentage of fruit and Nutrition Report consumption of 5 or more 10. Impact vegetables consumed in Nutrition serves of fruit and 2016 and 2021. STEPS Survey vegetables (survey based) DA 3. Family Health Services (Public Health Nurses) TMO Report MCH/FP Maternal Health 1. Output CPR use in 2016 and 2021 CIFWA Report Increase contraceptive UNICEF prevalence rate to 35% Census Improve measles vaccine Percentage measles vaccine 2. Output TMO Report Child health coverage to 98% coverage in 2021 Page | 89 UNICEF Establish a baseline and Baseline and targets set for targets for exclusive breast exclusive breast feeding rate TMO Report Maternal health 3. feeding rate on discharge Impact on discharge from maternity from maternity ward at 3 ward at 3 months and 6 Survey Report UNICEF months and 6 months months Rheumatic Heart Disease ECHO Screening of children 4. Output RHD report Child Health Complete screening of all 5-15 years children (5-15 years) Complete repeat screening Repeat screening for high 5. of high risk children subject output RHD report Child Health risk children completed to initial screening RHD database updated and Database updated and 6. Output RHD report Child Health maintained maintained All children with RHD to Prophylaxis treatment 7. receive prophylaxis Output received by all children with RHD report Child Health treatment RHD DA 4. Oral Health Implementation of Oral Process / Implementation Oral health 1 M&E report Oral health Health Strategy 2014-2018 Output strategy Develop new Oral Health Development of new oral Oral health 2 Output Oral health Strategy 2014-2018 health strategy strategy launched Dmft % changes in 5 year Dental Report Reduction by 30% from the 3 Impact olds between 2016 and Oral Health mean dmft 6.6 in 5 year olds 2021 Survey Report School Health Primary School tooth brush Primary school with Report 4 program established in at Output established tooth brush Oral Health least 90% of schools program. MOE Report Page | 90 Reduction by 30% in tooth Dental Report Percentage of tooth decay 5 decay prevalence in Primary Impact Oral health in primary schools. Schools (80%). Survey Report DA 5. Mental Health Implementation of the Implementation of Mental M&E Report Mental health Process / 1 mental health and well- Health and Well-being Output 12 being strategy 2016-2021 Strategy Program Report WHS Implementation of the Process / Implementation of Suicide 2 suicide prevention strategy M&E report Mental health Output Prevention Strategy 2016-2021 Review reports Review and develop new Mental health Review completed and new and new 3 strategies for mental health Output strategies developed strategies and suicide prevention WHS launched Update mental health Mental Health Updating of Mental Health Mental health 4 register with diagnosis Output Register report clearly tabulated WHS Mental Health TMO Report A 50% reduction in the Reduction in deaths from Suicide 5 Impact completed suicide rate. suicide attempts. Prevention Police Report WHS TMO Report Mental Health A 20% reduction in the Reduction in attempted Police Report Suicide 6 Impact attempted suicide reporting suicides. Prevention Punanga Tauturu report WHS 12 WHO World Health Statistics Page | 91 KRA 3 Targets INDICATOR TARGET DEFINITION / DESCRIPTION DATA SOURCES TOPIC TYPE GOPD/A&E Reduce by 20% the current Survey Report Access (2016) waiting time for Waiting time at GOPD 1. Output patients (less than 99 attendance. TMO Report Primary Care minutes). All GOPD patients are Early identification and Access processed through triage for 2. Output management of urgent TMO report early identification and cases Primary care management of urgent cases. Surgery and Anesthesia Theatre Report Secondary Perioperative mortality rate Post-operative deaths Care 1. (POMR) after 30 days is Impact within 30 years over total HIS Report maintained at Zero. surgeries. Surgical TMO Report Secondary Post-operative infection rate HIS Report Percentage of post- Care 2. (POIR) maintained below 20% Impact operative infections. of 2016 figures. TMO Report Surgical All department nursing staff Nursing staff trained in HR 3 Output HR report trained in Critical Care Nursing critical care development Secondary Introduce interventional Interventional endoscopy Care 4 Output TMO report endoscopy. introduced Surgical Obstetrics and Gynaecology Page | 92 Preventive Incidence of premature labour ANC Number of prem labor in 1. and births reduced by 50% Impact TMO Report 2021 over 2017 in %. from current rate of 2.9%. Obstetrics SDG Preventive Increase PAP smear screening TMO Report ANC to cover 80% women in the Number of PAP smear 2. Output reproductive age group and undertaken over CBA in % O&G Report Gynecology beyond (21-65 years). WHS Health information Maintain zero maternal 3. Impact No maternal deaths Statistical bulletin unit mortality. SDG Reduce sexually transmitted Gynecology Chlamydia infection rates 4. infection especially chlamydia Impact TMO report are reduced from 2016 rates among the antenatal women. WHS Medicine Secondary Cardiac ECHO undertaken on Percentage of ECHO done Process / Care 1. all (100%) patients over recommended TMO Report Output recommended for screening. number. Cardiac Secondary Introduce treadmill stress test Process / Introduction of treadmill Care 2. TMO Report assessment capability Output stress test option. Cardiac Rheumatic Heart Disease Preventive H Process / Establishment and use of 3. Register established for health TMO Report Output RHD register. / country. Cardiac 4. Impact TMO Report Reduce myocardial infarction Number of MI in 2021 over Secondary Page | 93 by 5%. number of MI in 2017 in % Care Cardiac NCD Secondary Reduce cerebrovascular Number of CVA in 2021 over Care 5. Impact TMO Report accidents by 5%. number in 2017 by % NCD Preventive H Number of end stage renal Reduce end stage renal failure Secondary 6. Impact in 2021 over number in TMO Report by 5%. Care 2017 in % NCD Increase compliance to Increase compliance to rheumatic heart disease 7. rheumatic heart disease Impact TMO report NCD prophylaxis treatment from prophylaxis treatment 2016 level. Paedeatrics Declaration and Child Health Rarotonga Hospital declared Hospital declared under 1. Impact official plaque of Baby Friendly Hospital BFHI commemoration UNICEF All Paediatric nursing staff/ Child Health 2. midwives trained in neonatal Output All nursing staff trained HR report resuscitation. UNICEF Ophthalmology Preventive H Diabetic retinopathy data base Creation of retinopathy data 1. Output TMO Report established base. NCD Annual outreach Program Outreach program every Primary Eye 2. Output TMO report implemented year Care Page | 94 Medical Referral Service Hospital Data Access Reduce number of chartered Number of charted flights in 1. flights to the Pa Enua from Impact 2021 over 2016 in % Administrative Secondary 2016 level Records Care Hospital Data Access Reduced number of referrals Number of charted flights in 2. to Rarotonga and New Impact 2021 over 2016 in % Administrative Secondary Zealand from 2016 level. Records Care Specialist Care TMO Report Preventive H At least 12 HSV programs Process / 12 or more HSV programs 1. implemented yearly. Output implemented ECHO Report Cardiac Establish a Radiologist service Secondary TMO Report with Middlemore Hospital to Process / Radiologist service Care 2. report on all x-ray images Output established ENT Report from the Cook Islands. ENT Establish eligibility criteria for high risk orthopaedic cases to Tertiary Care prioritise funding of one case Process / 3. Eligibility criteria established TMO report per year (total hip Output Surgery replacement and knee replacement surgeries). Page | 95 KRA 4 Targets INDICATOR TARGET DEFINITION / DESCRIPTION DATA SOURCES TOPIC TYPE Pharmacy Acquire and operate a new IT system 1. ICT system that improves on Process/output ICT installed and operational TMO Report Pharmacy the existing Toniq system Essential Medicine list reviewed every two years Review and alignment of Department 2. and align to Anti-Microbial Output Pharmacy EML every 2 years Report Resistance Action Plan and Anti-Biotic guidelines Nil Stock out for NCD 3. (Diabetes, Hypertension) Output Nill stock out TMO Report Pharmacy medications. Physiotherapy Explore alternatives for Exploration of Hydrotherapy Rehabilitation 1. hydrotherapy facilities and Output TMO Report option. Physiotherapy services. Certified ultrasound training Certified musculo-skeletal Rehabilitation 2. service for musculo-skeletal Output TMO Report service in operation. Physiotherapy cases completed. Laboratory Assess and report on best options for Laboratory Process / IT system 1. Assessing options for LIS. TMO Report Information System software Output Laboratory (LIS). Maintain quality assurance Assessing quality assurance 2. Output TMO report laboratory laboratory standards. standards. Unqualified audit report for Assessing laboratory 3. Output Audit report Laboratory laboratory inventory yearly inventory. Radiology TMO Report Policy & Radiology Service Plan Radiology service plan 1. Output Administrative Planning Formulated formulated an in use. Report Radiology Develop a Radiology Diagnostic 2. Equipment management Output Development of policy TMO report Radiology policy. Scoping exercise on radiology Scoping of radiology service Department Radiology 3. capabilities in Aitutaki Output introduction to Aitutaki. Report Diagnostic hospital Biomedical Medical Equipment TMO Report Policy and Medical Equipment Donation 1. Output Donation Policy formulation Administrative Planning Policy developed and adoption. Biomedical Page | 96 Policy and Medical Asset Management 2. Output Development of Policy TMO Report Planning Policy developed Biomedical Policy and Oxygen Plant Management Development of Oxygen 3. Output TMO report Planning Plan developed Management plan Biomedical Ambulance/Paramedic Services Med Evacuation Ambulance dispatch time Process / Ambulance dispatch time 1. TMO Report Emergency maintained at 3 minutes. Output from call to dispatch to site. response Advance level care delivered Advance level care delivered Med Evacuation 2. to all identified high risk Output to all identified high risk TMO report Emergency patients patients response Dietary Services Dietary counselling services 1. offered for all non-compliant Output Counselling services offered TMO report Dietary services cases. KRA 5 Targets INDICATOR TARGET DEFINITION / DESCRIPTION DATA SOURCES TOPIC TYPE Community Health Care Completed (100%) health Pa Enua profile of each Pa Enua Community health statistics Health profile 1. Output Station Report (demography, health and profiling of Pa Enua. report. HIU wellbeing) 40% of all private dwellings % of total dwellings on Aitutaki inspected, Process / Environmental 2. inspected, assessed and TMO report assessed and meet the Output health compliant Sewage Regulation 2014 % of total commercial 50% commercial properties Process / properties compliant of the Environmental 3. on Aitutaki comply with the TMO report Output total number of commercial health Sewage Regulation 2014 properties. Tobacco use reduction of Tobacco Reduce smoking by 20% of 4. Impact 20% from current 2015 STEPS control current level of smokers. STEPS levels NCD TB Unit/ Achieve 100% DOTS coverage 5. Output 100% coverage TB report Health (TB). Promotion Increase compliance to Treatment compliance from Pa Enua and 6. rheumatic heart disease Output TMO report 2016 levels Child Health prophylaxis treatment. Improve measles vaccine Improved coverage from Pa Enua and 7. Output TMO report coverage to 98% 2016 levels Child Health Establish exclusive Exclusive breastfeeding rate Obstetrics breastfeeding rate on TMO report 8. Output monitoring at discharge, 3 MCH discharge from birth 3months Station Report and 6 months UNICEF and 6months Page | 97 Pre-schoolers and Primary Oral health program oral health preventive TMO report Dental services 9. Output established in pre and program established in 100% Pa Enua report School health primary schools. of schools. Identify and register all Process / Registration of mental Mental health 10 patients with a mental health TMO report Output health patients WHS illness Less than 10 complaints Complaints in a given year 11. received for non-compliance Output under Food Act and TMO report Food Safety to Food Act and Regulations. Regulation Less than 10 complaints Water/ Complaints in a given year 12. received for water borne Output TMO report environmental on water borne illness related illnesses health Register number/type of Sewage and 13. Output Register established TMO report toilets in private dwellings. sanitation Community Health Services Community 14. Geographic Information Output System established TMO report Health System established HIU Preventive H IMCI introduced to all Pa IMCI introduced to Pa Enua Primary Care 15. Output TMO Report Enua stations. stations Child Health UNICEF Access HSV outreach program HSV services undertaken in TMO Report 16. Output Secondary implemented yearly. Pa Enua. HSV Report Care Clinical Services Cardio Vascular Risk Assessment of all Assessment of all Process / 1. recommended patients 40 TMO report NCD recommended patients 40 Output years and above. years and over. Incidence of premature Incidence of premature Obs & Gynae labour and births reduced 2. labour and births reduced by Impact TMO report MCH by 50% from current rate of 50% SDG 2.9%. Increase PAP smear screening PAP smear screening to to cover 80% women in the cover 80% women in the 3. Output TMO report Obs and Gynae reproductive age group and reproductive age group and beyond. beyond (21-65 years). Integrated Management of Childhood Illnesses 4. Output IMCI introduced TMO report Child Health introduced to all Pa Enua stations. Aitutaki Hospital declared Hospital declared under Declaration and Administration 5. Baby Friendly Hospital by Output BFHI plaque UNICEF 2021. Page | 98 Medical equipment and Maintained and updated 6. assets maintained and Output TMO report Biomed annually updated annually. Reduction by 30% from the Reduction by 30% from the 7. Impact mean dmft 6.6 in 5 years TMO report Dental mean dmft 6.6 in 5 years old. old. Reduction by 30% in tooth Reduction by 30% in tooth 8. decay prevalence in Primary Impact decay prevalence in Primary TMO report Dental Schools (80%). Schools (80%). Reduction by 30% in the Reduction by 30% in the mean DMFT (7.3, 12.9 and mean DMFT (7.3, 12.9 and 9. Impact 21.9) of the adult TMO report Dental 21.9) of the adult population population of WHO indexed of WHO indexed age groups. age groups. Nil Stock out for essential medicines especially NCD Nil stock out for NCD 10. Output TMO report Pharmacy (Diabetes, Hypertension) essential medicines medications Pa Enua health centres/residences at Atiu, Refurbishment of identified TMO report Maintenance 11 Mangaia, Mauke and Output stations CIIC Report Infrastructure Pukapuka refurbished to appropriate standards. Renovation of Aitutaki Renovation of Aitutaki TMO report Maintenance 12 Output Hospital completed. Hospital CIIC report Infrastructure Page | 99 Country Coordinating Mechanism The implementation of the NHSP will be supervised and monitored by the NHSP Supervisory Committee (NSC) led by Te Marae Ora (TMO), with involvement of subnational stakeholders, other ministries, CSOs, the private sector, academic institutions and development partners. The Planning Unit of the TMO will be the focal point and Chair to the CC. Regular meetings will be scheduled with minutes circulated to all senior staff and partners for information and action. Minutes will also provide input to the M&E function of the NHSP. NHSP Supervisory Committee The following structure and membership of the NHSP supervisory committee is proposed under the overall supervision of the Secretary for Health. Director Funding & Planning MFEM/OPM Rep Director CHS Manager Policy and Research PSC Rep Director HHS INTAFF 2 x NGO Reps Country Progress and Performance Review Mechanism Reviews are based on the evidence gathered through monitoring processes and require national institutional mechanisms involving multiple stakeholders. Existing country health-sector review processes are a key entry point for assessing progress and performance, and can influence priority-setting and resource allocation. Such reviews need to be systematically linked to actions in countries and provide the basis for mutual accountability. Schedule of Reviews 1. Annual Reviews – at the end of each calendar year 2. Mid-term Review – at the end of 2019 3. Final situation analysis and evaluation – at the end of 2021. The review will draw on information obtained from the Health Information Unit and from individual health program reviews and reports. The annual review are expected to feed into the Business Plan formulation process for funding and resource allocation. Page | 100 Chart 10: Progress and Performance Review Structure Data Sources The use of existing data from all data sources is required to assess progress and performance of the NHSP. It is therefore essential to specify how data on all components of health systems will be generated, including inputs, processes, outputs, outcomes and impact. The main data sources include the following.  Census of population and housing. This is the primary information source for determining the size of a population, its geographical distribution, and its social, demographic and economic characteristics.  Civil registration and vital statistics systems. The TMO collects its own births and deaths statistics but the M&E component will include a statement on the use of vital statistics and on planned ways to improve the availability and quality of data on births, deaths and causes of death.  Population-based health surveys with a focus on service coverage, equity and population health outcomes. The STEP Survey for NCD and Demographic Health Survey (DHS) are such population based surveys frequently used in the Pacific and could provide important information outside of the national census.  Facility generated data, including routine facility information systems and health facility assessments and surveys. The Health Information Unit will have most statistics of facility generated data.  Health program generated data, some program areas maintain their own data from outreach programs and special clinics or intervention activities. These data are more specific to interventions and should be included as data sources both for M&E and planning activities.  Administrative data sources including Parliamentary briefs, financial resource flows and expenditures to all levels and includes annual reporting of expenditures by major program. Page | 101 Data Dissemination and Communication The NHSP Supervisory Committee should determine from the M&E findings as to what specifics of the analytical outputs that will be produced as the basis for decision-making, program management, financial disbursements and global reporting. The key outputs of the health information systems that serve the basis for national and global reporting are discussed below. 1. Health Sector Progress and Performance Report A health sector progress and performance report is the key input for NHSP annual reviews and is based on the analysis and synthesis work described in the previous section. This includes a systematic assessment of progress against specific objectives and goals in the national health strategy, as well as in disease-specific plans. The health sector progress and performance report brings together all data from the different sources, including the facility reporting system, household surveys, administrative data and research studies, to answer the key questions on progress and performance using the country’s core indicators and health goals. 2. Annual Health Statistical Report The Cook Island TMO produces annual health information bulletins. This report presents a comprehensive analysis of all health data derived from administrative and health facility reporting, including the most relevant data by island. The annual health bulleting report provides ample attention to data quality issues, including timeliness, completeness and accuracy of reporting, as well as to data adjustments and methods used, if applicable. 3. Policy Briefs Policy briefs usually highlight actionable recommendations for decision-making in a 2–6 page format. The typical format identifies a problem, proposes a solution and presents a compelling and feasible recommendation. Non- academic language is used and images, quotes, photographs, and bullets are recommended. The supporting evidence is also highlighted. This format is ideal for conveying specific evidence-based policy recommended. 4. Colour Coding Colour coding is a strategy used to group data and suggest action. Most commonly the colours red, green and yellow are used to depict a traffic stop light. Specific numerical ranges are pre-determined for each colour and indicator, based on progress towards a programmatic target. This technique allows decision-makers to see at a glance if action is required around a specific indicator. There are similarities with this strategy and with the grading found in health report cards. Page | 102 NHSP Consultation Process 1. Evaluation of NHSP 2012-2016 TMO participants at the NHPS 2012-2016 review meeting at Crown Beach Hotel. This meeting also served as a forum for early inputs to the new NHSP. Hon. Minister and Secretary for Health along with WHO and SPC representatives were also present at the meeting. 2. National Health Strategy Seminar A national health strategy seminar was organised by Ministry of Health that invited stakeholders to participate in a consultative process on the new health strategy. Separately, consultations within the TMO took place with all key staff included in the discussions. Page | 103 People Consulted Name Name Name Teuvira Upokotea All MoH Staff Cook Islands Opposition of government members Barbra Allpress Vaka Ngaro Pa Enua Executive officers Anna Rasmussen NZ high comm Otheniel Tangianau Tangata Vainerere Creative Centre Mens Rotaianga Nooapii Tearea Cook Islands Tuaine Masters National Disability Council Bredina Drollet Taputu Mariri Iro Rangi Mereana Taikoko Tingika Elikana Shannon Saunders Nooroa Numanga John Strickland Gaye Whitta Desmond Amosa Maara Tetava Rongo File John Tangi Paul Lynch Ngarima George Jesse Evans Joseph Mayhew Ben Ponia Eliza Puna Alex Herman Lydia Nga Adam Bedouin Rose Brown Garth Henderson Milly Tamaki Tamaiva Tuavera Niki Rattle Russel Thomas Daphne Ringi Marino Wichman Tangianau Manuel Oropai Mataroa Angeline Tuara Anthony Brown Mataitirangi Cook Islands Members of Purea Parliament Lydia sijp-Marsters Elizabeth Koteka Ruth Pokura Claudine Henry Anguna Halatoa Fua Chamber of Commerce Tutai Matenga Anthony Turua Tristan Metcalfe Rimmel Poila Nga Teinangaro Ruby Ngavavia Elizabeth Munro Sieni Tiraa Teautoa Peua Mary Dean Teariki Ngaoire Tupe Tamatoa Poko Rota Joseph Brider Tupa Tupa Peria Daniel Ngametua Pokino Kendrick Rima Teava Iro Owen Lewis Regina Potini Losirene Lacanivalu Tamarii Tutangata Maeaki Hafoka Ngatoko Ngatoko Jane Kaina Vavia Tangatataia Tearuru Takai Petero Okotai Eirangi Masters Donna Smith Martha Nikoia Elizabeth Munro Kathleen Wilkie Ana Tiraa George Turia Gail Townsend Luke Brown Rosita Taikakara Danielle Cochrane Elizabeth Nootai George Maggie Niki Rattle Gill Ngatokorua Naomi Manavaikai Ben Ponia Pio Ravarua Eliu Eliu Ngarima George Cook Islands Child Patrick Arioka welfare association Polly Tongia Religious Advisory Tevai Tatuava council Naomi Manavaikai Daryl Rairi Marino Wichman Maeva Maeva Cook Islands Red Turi Mataiapo Cross Page | 104 Nii Tara Ui Ariki/Koutu Nui Bouchard Solomona Kimi Largering Bredina Drollet Lavinia Rasmussen Amelia Borofsky Sue Ngatokorua Heiarii Ioaba Vaine Wichman Nooroa Numanga All cook islands gov users Page | 105 Strategic Planning Process The evaluation of the previous 5 year health strategy and the development of this 5 year health strategy was carried out under the WHO Joint Assessment of National Strategy framework (WHO JANS) by Dr. Lepani Waqatakirewa and the local team consisting of Roana Mataitini and Valentino Wichman of the Funding and Planning Directorate of Te Marae Ora. This framework provided guidance in the planning process. Joint assessment is a shared approach to assessing the strengths and weaknesses of a national strategy, which is accepted by multiple stakeholders, and can be used as the basis for technical and financial support. There is renewed interest in joint assessments because there is strong consensus that sustainable development requires harmonized support to national processes. In developing the current 5 year health strategy a combination of the following theoretical frameworks were utilized. It must be noted that there is no internationally recommended framework for health strategic planning and every country plans according to their situation. International best practices recommend five criteria under the WHO JANS as the basis for strategic planning. The following are some theoretical frameworks used for general strategic planning. Aspects of these frameworks can be adapted for local planning: Bryson (1998) 1. Initiating and agreeing on a strategic planning process 2. Identifying organizational mandates 3. Clarifying organizational mission and values 4. Assessing the external and internal environments to identify strengths, weaknesses, opportunities and threats 5. Identifying the strategic issues facing an organization 6. Formulating strategies to manage the issues 7. Review and adopt the strategies or strategic plan 8. Establish an effective organizational vision 9. Develop an effective implementation process 10. Reassess the strategies and the strategic planning process Olsen and Eadie (1980) 1. The overall mission and goals statements 2. The environmental scan or analysis 3. The internal profile and resource audit 4. The formulation, evaluation and selection of strategies 5. The implementation and control of strategic plan Osborne and Gaebler (1992) 1. Analysis of the situation (Internal and External) 2. Diagnosis – key issues facing the organization 3. Definition of fundamental mission 4. Articulation of basic goals 5. Creation of a vision – what success looks like 6. Development of a strategy to realize vision and goals 7. Development of a time-table 8. Measurement and evaluation of results Page | 106